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1571 B Use BLUE or BLACK Ink i For Office Use j Permit ~I ILD p i a l i My of Eapo 4 5~ • a Permit Fee: 3830 Pilot Knob Road Eagan MN 55122 ~ Date Received: Eagan ~4 Al Phone: (851) 675-5675 I I Fax: (651) 675-5694 1 Staff.. 2013 RESIDENTIAL BUILDING PERMIT APPLICATION Date: 3 - site Address: is 1 ! 19, 131 Name: Yz- 4zn_~s____ Phone: (V-2- 72, - S a~ Resident/ "Owner Address / City / Zip: Applicant is: _ Owner Contractor Description of work: Remo F n - T Kleof Work Construction Cor, `'?.l_& C5 Multi-Family Building: (Yes No Company: C PJI'3 VC Contact: 2~f en %_.1 1LJ ContractOr Address: City: ~ ~IaRA~Jfc~.s State: ML Zip: Phone: mac? ZS - License SC - 210 6 2- Lead Certificate If the project is exempt from lead certification, please explain why: (see Page 3 for additional information) COMPLETE THIS AREA ONLY IF CONSTRUCTING A NEW BUILDING In the last 12 months, has the City of Eagan issued a permit for a similar plan based on a master plan? -Yes --No if yes, date and address of master plan: Licensed Plumber: Phone: Mechanical Contractor: Phone: Sewer $ Water Contractor: Phone: NOTE. Plans and supporting documents that you submit are considered to be public informatVon. Portions of the information maybe classified as non-public if you provide specific reasons that would permit the Clty to conclude that the are trade secrets. CALL BEFORE YOU DIG. Call Gopher State One Call at (651) 454-0002 for protection against underground utility damage. Cali 48 hairs before you intend to dig to receive locates of underground utilities. www.uoohen3tate2ne0ll.or_Q I hereby acknowledge that this information is complete and accurate; that the work will be in conformance with the ordinances and codes of the City of Eagan; that I understand this is not a permit, but only an application for a permit, and work is not to start without a permit; that the work will be in accordance with the approved plan in the case of work which requires a review and approval of plans. Exterior work authorized by a building permit issued in accordance with the Minnesota State Building Code must be completed within 180 days of permit issuance. xfr_ rn_a en x Applicant's Printed Name Applica s Signature 49 Page 1 of 3